Occipital Nerve Stimulation Form

MEDICAL COVERAGE POLICY SERVICE: Occipital Nerve Stimulation Policy Number: 074 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 1 of 5 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Occipital Nerve Stimulation PRIOR AUTHORIZATION: Required in some instances. POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for details. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) 160.7 Electrical Nerve Stimulators. If there are no applicable NCD or LCD criteria, use the criteria set forth below. CMS recognizes two general classifications of electrical nerve stimulators for treatment of chronic intractable pain: peripheral nerve stimulators and central nervous system stimulators. Payment may be made under the prosthetic device benefit for implanted peripheral nerve stimulators. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMcranial nerve neurostimulatorHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. For ALL other plans, BSWHP considers occipital nerve stimulation investigational/experimental or unproven This modality has not been shown to have any proven benefit in intractable headache and that many non-invasive methods of pain control are available. BACKGROUND:
Occipital nerve stimulation (ONS) delivers a small electrical charge to the occipital nerve in an attempt to prevent migraines and other headaches or to treat occipital neuralgia in patients who have not responded to medications. The device consists of a subcutaneously implanted pulse generator (in the chest wall or abdomen) attached to extension leads that are tunneled to join electrodes placed across one or both occipital nerves at the base of the skull. Continuous or intermittent stimulation may be used. Implanted peripheral nerve stimulators have been used for treatment of refractory pain for many years but only recently proposed for management of craniofacial pain. Occipital, supraorbital, and infraorbital stimulation have been reported in the literature. ONS has not been shown to have any proven benefit in intractable headache and that many non-invasive methods of pain control are available.

MEDICAL COVERAGE POLICY SERVICE: Occipital Nerve Stimulation Policy Number: 074 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 2 of 5 Occipital neuralgia (ON) is a rare neurological disorder characterized by piercing, throbbing, or electric- shock-like pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Typically, the pain of ON begins in the neck and spreads upwards. Some individuals also experience pain in the scalp, forehead, and behind the eyes. The location of pain is related to the course of the greater and lesser occipital nerves, which runs from the site at which the spinal cord meets the skull, up to the scalp at the back of the head. ON can occur due to irritation or injury of the occipital nerve; however, in many cases the cause is unknown. A wide range of therapies has been used for the management of intractable ON. Conservative treatment options include analgesics and other types of drugs, which may be supplemented with injections of anesthetic and steroid to reduce inflammation and block transmission of pain signals. If conservative treatments fail, patients with ON may undergo surgery to decompress or destroy segments of the occipital nerve. These surgical techniques are highly invasive, and they may not provide complete, long-term relief. MANDATES: None CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays 61888 Revision or removal of cranial neurostimulator pulse generator or receiver 64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve 64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 64569 Revision or replacement of cranial nerve (eg vagus nerve) neurostimulator electrode array, including connection to existing pulse generator 64575 Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver ICD10 codes G43.xxx Migraine G44.0xx Cluster headaches and other trigeminal autonomic cephalgias G44.1 Vascular headache G44.2xx Tension-type headache

MEDICAL COVERAGE POLICY SERVICE: Occipital Nerve Stimulation Policy Number: 074 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 3 of 5 G44.5x Complicated headache syndromes R51 Headache HCPCS Codes C1767 Generator neurostimulator (implantable) non-rechargeable C1778 Lead, neurostimulator C1787 Patient programmer, neurostimulator C1816 Receiver and/or transmitter neurostimulator (implantable) C1820 Generator, neurostimulator (implantable), non-high frequency with rechargeable battery and charging system C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system C1897 Lead neurostimulator test kit (implantable) L8679 Implantable neurostimulator, pulse generator any type L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofrequency receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8685 Implantable neurostimulator pulse generator, single array, rechargeable includes extension L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable,includes extension POLICY HISTORY: Status Date Action New 10/1/2010 New policy Reviewed 8/30/2012 Reviewed. Reviewed 5/30/2013 CMS coverage updated. ICD10 codes added.. Reviewed 5/22/2014 No changes Reviewed 5/28/2015 No changes Reviewed 6/09/2016 No changes Reviewed 5/16/2017 No appreciable changes Reviewed 4/03/2018 No changes Reviewed 6/27/2019 Updated codes Reviewed 9/24/2020 Re-formatted for SWHP/First Care Reviewed 9/23/2021 No changes Reviewed 9/22/2022 No changes Reviewed 11/29/2023 Formatting changes, added hyperlinks to NCD and TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes

MEDICAL COVERAGE POLICY SERVICE: Occipital Nerve Stimulation Policy Number: 074 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 4 of 5

   Reviewed

03/11/2024 Corrected the “For Medicaid Plans” section to utilize this Medical Policy if TMPPM does not have medical necessity guidance.

   Updated

10/14/2024 Changed “Prior Authorization” section from “Not required” to “Required in some instances” in order to coincide with previously communicated PA requirements. No changes made to criteria and no new requirements for PA added.

   Reviewed

05/12/2025 Ending note section updated to align with CMS requirements and business entity changes.

   Updated

08/11/2025 Removed, “Medicare NCD or LCD specific InterQual criteria may be used when available.”

   Updated

05/28/2026 Updated references REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. Trentman TL, Rosenfeld DM, Vargas BB et al. Greater occipital nerve stimulation via the Bion Microstimulatro; implantation technique and stimulation parameters Clinical Trial: NCT00205894. Pain Physician 2009; 12(3):621-8.
2. Schwedt TJ, Dodick DW, Trentman TL et al. Occipital nerve stimulation for chronic headache--long-term safety and efficacy. Cephalalgia 2007; 27(2):153-7.
3. Schwedt TJ, Dodick DW, Trentman TL et al. Response to occipital nerve block is not useful in predicting efficacy of occipital nerve stimulation. Cephalalgia 2007; 27(3):271-4.
4. Burns B, Watkins L, Goadsby P. Treatment of intractable chronic cluster headache by occipital nerve stimulation in 14 patients. Neurology 2009; 72(4):341-5.
5. Burns B, Watkins L, Goadsby P. Treatment of hemicrania continua by occipital nerve stimulation with a bion device: long- term follow-up of a crossover study. Lancet Neurol 2008; 7(11):1001-12.
6. Reed KL, Black SB, Bant CJ 2 nd et al. Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience. Cephalalgia 2009 Sep 3 [Epub ahead of print].
7. Clinical Trials.gov. Accessible at http://clinicaltrials.gov/ct2/results?term=occipital+nerve+stimulation
8. British Association for the Study of Headache (BASH). Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type Headache, Cluster Headache, Medication-Overuse Headache. 2010. Available at: http://217.174.249.183/upload/NS_BASH/2010_BASH_Guidelines.pdf. Accessed May 5, 2012.
9. Chen YF, Bramley G, Unwin G, et al. Occipital nerve stimulation for chronic migraine—a systematic review and meta- analysis. PLoS One. 2015;10(3):e0116786.

MEDICAL COVERAGE POLICY SERVICE: Occipital Nerve Stimulation Policy Number: 074 Effective Date: 06/01/2026 Last Review: 05/28/2026 Next Review: 05/28/2027 Page 5 of 5

10. Maxey BS, Pruitt JW, Deville A, et al. Occipital nerve stimulation: an alternative treatment of chronic migraine. Curr Pain Headache Rep. 2022;26(4):337-346.
11. Strand N, D'Souza RS, Hagedorn JM, et al. Evidence-based clinical guidelines from the American Society of Pain and Neuroscience for the use of implantable peripheral nerve stimulation in the treatment of chronic pain. J Pain Res. 2022;15:2483-2504.
12. Petersen AS, Lund N, Goadsby PJ, et al. Recent advances in diagnosing, managing, and understanding the pathophysiology of cluster headache. Lancet Neurol. 2024;23(7):712-724.
13. Knotkova H, Hamani C, Sivanesan E, et al. Neuromodulation for chronic pain. Lancet. 2021;397(10289):2111-2124.
14. Leplus A, Fontaine D, Donnet A, et al. Long-term efficacy of occipital nerve stimulation for medically intractable cluster headache. Neurosurgery. 2021;88(2):375-383.
15. Membrilla JA, Roa J, Díaz-de-Terán J. Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis. J Neurol. 2023;270(2):689-710.
16. Ravaillault S, Alipour H, Leger F, et al. Occipital nerve stimulation for refractory occipital neuralgia: a multicenter, randomized, controlled trial [StimO Study]. J Clin Med. 2026;15(5):1922.
17. Kollenburg L, Kurt E, Mulleners W, et al. Four decades of occipital nerve stimulation for headache disorders: a systematic review. Curr Pain Headache Rep. 2024;28(10):1015-1034. Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan. RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.